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Sha Q, Escobar Galvis ML, Madaj ZB, Keaton SA, Smart L, Edgerly YM, Anis E, Leach R, Osborne LM, Achtyes E, Brundin L. Dysregulated placental expression of kynurenine pathway enzymes is associated with inflammation and depression in pregnancy. Brain Behav Immun 2024; 119:146-153. [PMID: 38555986 DOI: 10.1016/j.bbi.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Perinatal depression (including antenatal-, postnatal-, and depression that spans both timepoints) is a prevalent disorder with high morbidity that affects both mother and child. Even though the full biological blueprints of perinatal depression remain incomplete, multiple studies indicate that, at least for antenatal depression, the disorder has an inflammatory component likely linked to a dysregulation of the enzymatic kynurenine pathway. The production of neuroactive metabolites in this pathway, including quinolinic acid (QUIN), is upregulated in the placenta due to the multiple immunological roles of the metabolites during pregnancy. Since neuroactive metabolites produced by the pathway also may affect mood by directly affecting glutamate neurotransmission, we sought to investigate whether the placental expression of kynurenine pathway enzymes controlling QUIN production was associated with both peripheral inflammation and depressive symptoms during pregnancy. METHODS 68 placentas obtained at birth were analyzed using qPCR to determine the expression of kynurenine pathway enzymes. Cytokines and metabolites were quantified in plasma using high-sensitivity electroluminescence and ultra-performance liquid chromatography, respectively. Maternal depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS) throughout pregnancy and the post-partum. Associations between these factors were assessed using robust linear regression with ranked enzymes. RESULTS Low placental quinolinate phosphoribosyl transferase (QPRT), the enzyme responsible for degrading QUIN, was associated with higher IL-6 and higher QUIN/kynurenic acid ratios at the 3rd trimester. Moreover, women with severe depressive symptoms in the 3rd trimester had significantly lower placental expression of both QPRT and 2-amino-3-carboxymuconate-6-semialdehyde decarboxylase (ACMSD); impaired activity of these two enzymes leads to QUIN accumulation. CONCLUSION Overall, our data support that a compromised placental environment, featuring low expression of critical kynurenine pathway enzymes is associated with increased levels of plasma cytokines and the dysregulated kynurenine metabolite pattern observed in depressed women during pregnancy.
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Affiliation(s)
- Qiong Sha
- Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI, USA
| | | | - Zachary B Madaj
- Bioinformatics and Biostatistics Core, Van Andel Institute, Grand Rapids, MI, USA
| | - Sarah A Keaton
- Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI, USA
| | - LeAnn Smart
- Pine Rest Christian Mental Health Services, Grand Rapids, MI, USA
| | | | - Ehraz Anis
- Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI, USA
| | - Richard Leach
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University, East Lansing, MI, USA
| | - Lauren M Osborne
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA; Department of Psychiatry, Weill Cornell Medicine, New York, NY, USA
| | - Eric Achtyes
- Pine Rest Christian Mental Health Services, Grand Rapids, MI, USA; Department of Psychiatry, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Lena Brundin
- Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI, USA.
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Xodo S, Londero AP, Orsaria M, Marzinotto S, Colussi G, Cagnacci A, Mariuzzi L, Gri G. Examining the Aryl Hydrocarbon Receptor Network in the Placental Tissues of Pregnancies Complicated by Pre-Eclampsia: An Explorative Case-Control Analysis. Life (Basel) 2023; 13:2122. [PMID: 38004262 PMCID: PMC10672047 DOI: 10.3390/life13112122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023] Open
Abstract
Severe maternal and newborn morbidity and mortality associated with pre-eclampsia, which are caused partly by premature delivery, affect a factual proportion of pregnancies. Despite its prevalence, the underlying causes of pre-eclampsia remain elusive, with emerging evidence implicating the aryl hydrocarbon receptor (AhR) in its pathogenesis. This study sought to elucidate the involvement of the AhR and its associated pathway in pre-eclampsia by comparing placental components of the AhR pathway in pregnant individuals with and without pre-eclampsia. This case-control investigation was conducted at the University Hospital of Udine from May 2021 to February 2023. The AhR was assessed using immunohistochemistry and immunofluorescence, and its mRNA was evaluated using a Real-Time Quantitative Reverse Transcription PCR. Levels of mRNA expression were also estimated for other components of the AhR pathway (CYP1B1, IDO1, ARNT, TIPARP, S100A4, and AHRR). Our findings show decreased levels of expression of AhR, IDO1, ARNT, TiPARP, and S100A4 in the placental tissues of individuals with pre-eclampsia compared to controls (p < 0.05). The AhR exhibited a distinct localization within the syncytiotrophoblast (nuclei and cytoplasm) and CD45-positive cells (nuclei and cytoplasm). Furthermore, a significant positive correlation between the AhR and S100A4 (rho = 0.81) was observed in normal placentas, while CYP1B1 displayed a significant negative correlation with the AhR (rho = -0.72), within addition to its negative correlation with TiPARP (rho = -0.83). This study illuminates pre-eclampsia's molecular aberrations, suggesting new diagnostic, therapeutic, and mechanistic approaches. This study emphasizes the need for more research to validate and broaden these findings to improve the management of this complex pregnancy condition.
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Affiliation(s)
- Serena Xodo
- Clinic of Obstetrics and Gynecology, “Azienda Sanitaria Universitaria Integrata di Udine”, DAME, University of Udine, 33100 Udine, Italy
| | - Ambrogio P. Londero
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, 16132 Genova, Italy;
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy
| | - Maria Orsaria
- Institute of Pathology, “Azienda Sanitaria Universitaria Integrata di Udine”, DAME, University of Udine, 33100 Udine, Italy; (M.O.)
| | - Stefania Marzinotto
- Institute of Pathology, “Azienda Sanitaria Universitaria Integrata di Udine”, DAME, University of Udine, 33100 Udine, Italy; (M.O.)
| | - Gianluca Colussi
- Hypertension Unit, Department of Medicine, ASFO “Santa Maria degli Angeli” Hospital of Pordenone, 33170 Pordenone, Italy;
| | - Angelo Cagnacci
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, 16132 Genova, Italy;
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
| | - Laura Mariuzzi
- Institute of Pathology, “Azienda Sanitaria Universitaria Integrata di Udine”, DAME, University of Udine, 33100 Udine, Italy; (M.O.)
| | - Giorgia Gri
- DIMEC—Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy;
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Jasim ZA, Al-Hakeim HK, Zolghadri S, Stanek A. Maternal Tryptophan Catabolites and Insulin Resistance Parameters in Preeclampsia. Biomolecules 2023; 13:1447. [PMID: 37892130 PMCID: PMC10604911 DOI: 10.3390/biom13101447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/22/2023] [Accepted: 09/24/2023] [Indexed: 10/29/2023] Open
Abstract
Preeclampsia (PE) is a pregnancy-related disorder characterized by high blood pressure and proteinuria in the third trimester. The disease is associated with many metabolic and biochemical changes. There is a need for new biomarkers for diagnosis and follow-up. The present study examined the diagnostic ability of tryptophan catabolites (TRYCATs) and insulin resistance (IR) parameters in women with PE. This case-control study recruited sixty women with preeclampsia and 60 healthy pregnant women as a control group. Serum levels of TRYCATs (tryptophan, kynurenic acid, kynurenine, and 3-hydroxykynurenine) and IR parameters (insulin and glucose) were measured by ELISA and spectrophotometric methods. The results showed that PE women have a significantly lower tryptophan level than healthy pregnant women. However, there was a significant increase in kynurenic acid, kynurenic acid/kynurenine, kynurenine/tryptophan, and 3-hydroxykynurenine levels. PE women also have a state of IR. The correlation study indicated various correlations of IR and TRYCATs with clinical data and between each other, reflecting the role of these parameters in the pathophysiology of PE. The ROC study showed that the presence of IR state, reduced tryptophan, and increased 3-HK predicted PE disease in a suspected woman with moderate sensitivities and specificities. In conclusion, the pathophysiology of PE involves a state of IR and an alteration of the TRYCAT system. These changes should be taken into consideration when PE is diagnosed or treated.
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Affiliation(s)
- Zainab Abdulameer Jasim
- Department of Biochemistry, Shiraz Branch, Islamic Azad University, Shiraz 7198774731, Iran;
| | | | - Samaneh Zolghadri
- Department of Biology, Jahrom Branch, Islamic Azad University, Jahrom 7414785318, Iran
| | - Agata Stanek
- Department and Clinic of Internal Medicine, Angiology and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland
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Yaman S, Ceyhan M, Hancerliogullari N, Koc EM, Candar T, Tokmak A. Serum levels of kynurenine in pregnancies with fetal growth restriction and oligohydramnios. J Perinat Med 2023:jpm-2022-0446. [PMID: 36586131 DOI: 10.1515/jpm-2022-0446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/08/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Kynurinine (KYN) and its metabolites, which are released during the metabolism of tryptophan, an essential amino acid, have many important functions, such as cellular energy production, regulation of vascular tone, and regulation of the immune system. In this study, we aimed to detect serum KYN levels, which may be an indicator of KYN pathway activity, in idiopathic fetal growth restriction (FGR) and oligohydramnios cases whose pathophysiology is known to be affected by multiple factors, such as placental hypoperfusion, immune dysregulation, and maternal nutrition disorder, and to investigate their relationship with these common obstetric complications. METHODS This cross-sectional case-control study was carried out in the antenatal outpatient clinics of Ankara City Hospital between July and December 2021. While the study group consisted of pregnant women with idiopathic isolated FGR and oligohydramnios, the control group consisted of low-risk patients who did not have any problems. The clinical features of the patients, such as age, body mass indexes, and gestational week, were recorded by measuring basic laboratory parameters and serum KYN levels. RESULTS A total of 110 patients were included in this study. The patients were divided into three groups: FGR, oligohydramnios, and the control group. There was no significant difference between the patients' ages, weeks of gestation, or body mass indexes. Serum KYN level was calculated as 57.8 ± 13.4 pg/mL in IUGR, 75.3 ± 10.8 pg/mL in oligohydramnios and 95.1 ± 13.3 pg/mL in the control group (p<0.001). CONCLUSIONS Serum KYN levels were lower in pregnant women complicated with FGR and oligohydramnios more prominently in pregnant women diagnosed with FGR than in normal pregnancies. The results suggest that KYN plays an important role in either the etiopathogenesis or the response to these two obstetric pathologies.
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Affiliation(s)
- Selen Yaman
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Türkiye
| | - Meryem Ceyhan
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Türkiye
| | - Necati Hancerliogullari
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Türkiye
| | - Esin Merve Koc
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Türkiye
| | - Tuba Candar
- Department of Medical Biochemistry, School of Medicine, Ufuk University, Ankara, Türkiye
| | - Aytekin Tokmak
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Türkiye
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Marsden PA. The curious case of tryptophan in pregnancy. J Clin Invest 2022; 132:164219. [PMID: 36250464 PMCID: PMC9566892 DOI: 10.1172/jci164219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
For patients and caregivers to be fully informed about how living organ donation or prior kidney injury affects future health, we need to better understand the role of kidney reserve in physiological adaptation, especially during pregnancy. Importantly, epidemiological studies reason that live kidney donors are at increased risk for developing preeclampsia, a hypertensive disorder of pregnancy with serious implications for maternal and fetal health. Despite the import of this finding, the mechanistic basis for this increased risk is not understood. In this issue of the JCI, Dupont, Berg, and co-authors provide strong evidence that impaired placental perfusion, placental ischemia, increased soluble fms-like tyrosine kinase 1 (sFLT1), and a maternal preeclampsia–like phenotype are associated with an inability to upregulate the l-tryptophan–derived l-kynurenine pathway during pregnancy in mice with blunted renal reserve. These surprising revelations underscore the curious quiddity of l-tryptophan.
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Affiliation(s)
- Philip A. Marsden
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Unbalanced IDO1/IDO2 Endothelial Expression and Skewed Keynurenine Pathway in the Pathogenesis of COVID-19 and Post-COVID-19 Pneumonia. Biomedicines 2022; 10:biomedicines10061332. [PMID: 35740354 PMCID: PMC9220124 DOI: 10.3390/biomedicines10061332] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 05/29/2022] [Accepted: 06/02/2022] [Indexed: 11/17/2022] Open
Abstract
Despite intense investigation, the pathogenesis of COVID-19 and the newly defined long COVID-19 syndrome are not fully understood. Increasing evidence has been provided of metabolic alterations characterizing this group of disorders, with particular relevance of an activated tryptophan/kynurenine pathway as described in this review. Recent histological studies have documented that, in COVID-19 patients, indoleamine 2,3-dioxygenase (IDO) enzymes are differentially expressed in the pulmonary blood vessels, i.e., IDO1 prevails in early/mild pneumonia and in lung tissues from patients suffering from long COVID-19, whereas IDO2 is predominant in severe/fatal cases. We hypothesize that IDO1 is necessary for a correct control of the vascular tone of pulmonary vessels, and its deficiency in COVID-19 might be related to the syndrome’s evolution toward vascular dysfunction. The complexity of this scenario is discussed in light of possible therapeutic manipulations of the tryptophan/kynurenine pathway in COVID-19 and post-acute COVID-19 syndromes.
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An Emerging Cross-Species Marker for Organismal Health: Tryptophan-Kynurenine Pathway. Int J Mol Sci 2022; 23:ijms23116300. [PMID: 35682980 PMCID: PMC9181223 DOI: 10.3390/ijms23116300] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 02/01/2023] Open
Abstract
Tryptophan (TRP) is an essential dietary amino acid that, unless otherwise committed to protein synthesis, undergoes metabolism via the Tryptophan-Kynurenine (TRP-KYN) pathway in vertebrate organisms. TRP and its metabolites have key roles in diverse physiological processes including cell growth and maintenance, immunity, disease states and the coordination of adaptive responses to environmental and dietary cues. Changes in TRP metabolism can alter the availability of TRP for protein and serotonin biosynthesis as well as alter levels of the immune-active KYN pathway metabolites. There is now considerable evidence which has shown that the TRP-KYN pathway can be influenced by various stressors including glucocorticoids (marker of chronic stress), infection, inflammation and oxidative stress, and environmental toxicants. While there is little known regarding the role of TRP metabolism following exposure to environmental contaminants, there is evidence of linkages between chemically induced metabolic perturbations and altered TRP enzymes and KYN metabolites. Moreover, the TRP-KYN pathway is conserved across vertebrate species and can be influenced by exposure to xenobiotics, therefore, understanding how this pathway is regulated may have broader implications for environmental and wildlife toxicology. The goal of this narrative review is to (1) identify key pathways affecting Trp-Kyn metabolism in vertebrates and (2) highlight consequences of altered tryptophan metabolism in mammals, birds, amphibians, and fish. We discuss current literature available across species, highlight gaps in the current state of knowledge, and further postulate that the kynurenine to tryptophan ratio can be used as a novel biomarker for assessing organismal and, more broadly, ecosystem health.
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Tan KML, Tint MT, Kothandaraman N, Michael N, Sadananthan SA, Velan SS, Fortier MV, Yap F, Tan KH, Gluckman PD, Chong YS, Chong MFF, Lee YS, Godfrey KM, Eriksson JG, Cameron-Smith D. The Kynurenine Pathway Metabolites in Cord Blood Positively Correlate With Early Childhood Adiposity. J Clin Endocrinol Metab 2022; 107:e2464-e2473. [PMID: 35150259 PMCID: PMC9113811 DOI: 10.1210/clinem/dgac078] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The kynurenine pathway generates metabolites integral to energy metabolism, neurotransmission, and immune function. Circulating kynurenine metabolites positively correlate with adiposity in children and adults, yet it is not known whether this relationship is present already at birth. OBJECTIVE In this prospective longitudinal study, we investigate the relationship between cord blood kynurenine metabolites and measures of adiposity from birth to 4.5 years. METHODS Liquid chromatography-tandem mass spectrometry was used to quantify cord blood kynurenine metabolites in 812 neonates from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study. Fat percentage was measured by air displacement plethysmography and abdominal adipose tissue compartment volumes; superficial (sSAT) and deep subcutaneous (dSAT) and internal adipose tissue were quantified by magnetic resonance imaging at early infancy in a smaller subset of neonates, and again at 4 to 4.5 years of age. RESULTS Cord blood kynurenine metabolites appeared to be higher in female newborns, higher in Indian newborns compared with Chinese newborns, and higher in infants born by cesarean section compared with vaginal delivery. Kynurenine, xanthurenic acid, and quinolinic acid were positively associated with birthweight, but not with subsequent weight during infancy and childhood. Quinolinic acid was positively associated with sSAT at birth. Kynurenic acid and quinolinic acid were positively associated with fat percentage at 4 years. CONCLUSION Several cord blood kynurenine metabolite concentrations were positively associated with birthweight, with higher kynurenic acid and quinolinic acid correlating to higher percentage body fat in childhood, suggesting these cord blood metabolites as biomarkers of early childhood adiposity.
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Affiliation(s)
- Karen Mei-Ling Tan
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
- Department of Laboratory Medicine, National University Hospital, 119074, Singapore
| | - Mya-Thway Tint
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
- Department of Obstetrics and Gynaecology, Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (YLLSOM), National University of Singapore, 119228, Singapore
| | - Narasimhan Kothandaraman
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
| | - Navin Michael
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
| | - Suresh Anand Sadananthan
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
| | - S Sendhil Velan
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
- Institute of Bioengineering and Bioimaging (IBB), Agency for Science Technology and Research, 138669, Singapore
| | - Marielle V Fortier
- Department of Diagnostic and Interventional Imaging, KK Women’s and Children’s Hospital, 229899, Singapore
| | - Fabian Yap
- Duke-National University of Singapore (NUS) Medical School, 169857, Singapore
- Department of Pediatric Endocrinology, KK Women’s and Children’s Hospital, 229899, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, 636921, Singapore
| | - Kok Hian Tan
- Duke-National University of Singapore (NUS) Medical School, 169857, Singapore
- Perinatal Audit and Epidemiology, Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, 119228, Singapore
| | - Peter D Gluckman
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
- Liggins Institute, University of Auckland, Auckland 1023, New Zealand
| | - Yap-Seng Chong
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
- Department of Obstetrics and Gynaecology, Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (YLLSOM), National University of Singapore, 119228, Singapore
- Yong Loo Lin School of Medicine (YLLSOM), National University of Singapore, 117597, Singapore
| | - Mary F F Chong
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 117549, Singapore
| | - Yung Seng Lee
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
- Khoo Teck Puat – National University Children’s Medical Institute, National University Health System, 119074, Singapore
| | - Keith M Godfrey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, United Kingdom
- NIHR Southampton Biomedical Research Centre, University of Southampton Hospital, Southampton SO16 6YD, United Kingdom
| | - Johan G Eriksson
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
- Department of Obstetrics and Gynaecology, Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (YLLSOM), National University of Singapore, 119228, Singapore
- Folkhälsan Research Center, 00250 Helsinki, Finland
- Department of General Practice and Primary Health Care, University of Helsinki, 00290 Helsinki, Finland
| | - David Cameron-Smith
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), 117609, Singapore
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, 117596, Singapore
- Correspondence: Professor David Cameron Smith, Singapore Institute for Clinical Sciences, Brenner Centre for Molecular Medicine, Agency for Science, Technology and Research, 30 Medical Drive 117609, Singapore.
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Broekhuizen M, Danser AHJ, Reiss IKM, Merkus D. The Function of the Kynurenine Pathway in the Placenta: A Novel Pharmacotherapeutic Target? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111545. [PMID: 34770059 PMCID: PMC8582682 DOI: 10.3390/ijerph182111545] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 12/21/2022]
Abstract
(L-)tryptophan is metabolized via the kynurenine pathway into several kynurenine metabolites with distinct functions. Dysfunction of the kynurenine pathway can lead to impairments in vascular regulation, immune regulation, and tolerance. The first and rate limiting enzyme of this pathway, indoleamine 2,3-dioxygenase (IDO), is highly expressed in the placenta and reduced in placentas from complicated pregnancies. IDO is essential during pregnancy, as IDO inhibition in pregnant mice resulted in fetal loss. However, the exact function of placental IDO, as well as its exact placental localization, remain controversial. This review identified that two isoforms of IDO; IDO1 and IDO2, are differently expressed between placental cells, suggesting spatial segregation. Furthermore, this review summarizes how the placental kynurenine pathway is altered in pregnancy complications, including recurrent miscarriage, preterm birth, preeclampsia, and fetal growth restriction. Importantly, we describe that these alterations do not affect maternally circulating metabolite concentrations, suggesting that the kynurenine pathway functions as a local signaling pathway. In the placenta, it is an important source of de novo placental NAD+ synthesis and regulates fetal tryptophan and kynurenine metabolite supply. Therefore, kynurenine pathway interventions might provide opportunities to treat pregnancy complications, and this review discusses how such treatment could affect placental function and pregnancy development.
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Affiliation(s)
- Michelle Broekhuizen
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
- Division of Neonatology, Department of Pediatrics, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
- Division of Experimental Cardiology, Department of Cardiology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
- Correspondence:
| | - A. H. Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Irwin K. M. Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
- Walter Brendel Center of Experimental Medicine, University Clinic Munich, LMU Munich, 81377 Munich, Germany
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Murthy GG, Prideaux MA, Armstrong M, Kenney HM, Latchney SE, Susiarjo M, Murphy SP. Characterization of the temporal, cell-specific and interferon-inducible patterns of indoleamine 2,3 dioxygenase 1 (IDO1) expression in the human placenta across gestation. Placenta 2021; 115:129-138. [PMID: 34619429 DOI: 10.1016/j.placenta.2021.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/09/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The human placenta performs multiple functions necessary for successful pregnancy, but the metabolic pathways and molecular mechanisms responsible for regulating placental development and functions remain incompletely understood. Catabolism of the essential amino acid tryptophan has numerous critical roles in normal physiology, including inflammation. The kynurenine pathway, which accounts for ∼90% of tryptophan breakdown, is mediated by indoleamine 2,3 dioxygenase 1 (IDO1) in the placenta. In pregnant mice, alterations of IDO1 activity or expression result in fetal resorption and a preeclampsia-like phenotype. Decreased IDO1 expression at the maternal-fetal interface has also been linked to preeclampsia, in utero growth restriction and recurrent miscarriage in humans. These collective observations suggest essential role(s) for IDO1 in maintaining healthy pregnancy. Despite these important roles, the precise temporal, cell-specific and inflammatory cytokine-mediated patterns of IDO1 expression in the human placenta have not been thoroughly characterized across gestation. METHODS Western blot and whole mount immunofluorescence (WMIF) were utilized to characterize and quantify basal and interferon (IFN)-inducible IDO1 expression in 1st trimester (7-13 weeks), 2nd trimester (14-22 weeks) and term (39-41 weeks) placental villi. RESULTS IDO1 expression is activated in the human placenta between the 13th and 14th weeks of pregnancy, increases through the 2nd trimester and remains elevated at term. Constitutive IDO1 expression is restricted to placental endothelial cells. Interestingly, different types of IFNs have distinct effects on IDO1 expression in the human placenta. DISCUSSION Our collective results are consistent with potential role(s) for IDO1 in the regulation of vascular functions in placental villi.
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Affiliation(s)
- Gayathri Guru Murthy
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Mallory A Prideaux
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Madison Armstrong
- Department of Environmental Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - H Mark Kenney
- Department of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sarah E Latchney
- Department of Environmental Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Martha Susiarjo
- Department of Environmental Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Shawn P Murphy
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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11
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Worton SA, Pritchard HAT, Greenwood SL, Alakrawi M, Heazell AEP, Wareing M, Greenstein A, Myers JE. Kynurenine Relaxes Arteries of Normotensive Women and Those With Preeclampsia. Circ Res 2021; 128:1679-1693. [PMID: 33656370 PMCID: PMC8154175 DOI: 10.1161/circresaha.120.317612] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Supplemental Digital Content is available in the text. Rationale: Activation of the kynurenine pathway of tryptophan catabolism by infection and inflammation contributes to the development of systemic hypotension. Commercially-available kynurenine has direct vasorelaxant effects on arteries from several species and reduces systemic blood pressure when administered to normotensive or hypertensive rats. Objectives: To determine whether kynurenine promotes relaxation of human resistance arteries from normotensive and hypertensive pregnant women and to identify the vascular mechanism of its effects. Methods and Results: In isolated omental and myometrial resistance arteries from normotensive pregnant women, kynurenine (1 mmol/L) significantly reduced U46619-induced constriction (omentum N=14, P=2.4×10−3; myometrium N=21–25, P=2.6×10−4) and relaxed preconstricted arteries (N=53, P=1.0×10−11; N=20, P=8.8×10−3). Vasorelaxation persisted following endothelium removal (N=7, P=1.6×10−4) but was completely prevented by inhibition of large-conductance Ca2+-activated K+ channels (BKCa) channels with iberiotoxin (N=9, P=5.7×10−4) or paxilline (N=10, P=2.1×10−17). Accordingly, in isolated vascular smooth muscle cells from omental arteries, kynurenine increased the BKCa current (n=5–8, P=0.022) and the amplitude of spontaneous transient outward currents (n=6, P=0.031) but did not affect spontaneous transient outward current frequency. Kynurenine also increased Ca2+ spark frequency of pressurized omental arteries (n=8, P=0.031). Vasorelaxant effects of kynurenine persisted following inhibition of ryanodine receptors (N=7, P=0.48) but were moderately reduced by inhibition of adenylate cyclase (N=9, P=0.024). In arteries from women with preeclampsia, kynurenine similarly attenuated vasoconstriction (N=15, P=1.3×10−5) and induced BKCa-mediated vasodilation (N=16, P=2.0×10−4). Vasorelaxation in response to kynurenine and a specific BKCa activator, NS11021, was absent in fetal-derived placental resistance arteries in normal pregnancy and preeclampsia. Conclusions: Kynurenine dilates systemic arteries from multiple territories via BKCa activation. Notably, the vasorelaxatory capacity of kynurenine is preserved in preeclampsia, suggesting this approach may have translational potential for the treatment of hypertension in pregnancy. The data warrant further investigation of the potential to exploit this endogenous vasorelaxant as a new treatment for hypertensive pathologies.
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Affiliation(s)
- Stephanie A Worton
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom (S.A.W., S.L.G., A.E.P.H., M.W., J.E.M.).,Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom (S.A.W., A.E.P.H., A.G., J.E.M.)
| | - Harry A T Pritchard
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom (H.A.T.P., M.A., A.G.)
| | - Susan L Greenwood
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom (S.A.W., S.L.G., A.E.P.H., M.W., J.E.M.)
| | - Mariam Alakrawi
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom (H.A.T.P., M.A., A.G.)
| | - Alexander E P Heazell
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom (S.A.W., S.L.G., A.E.P.H., M.W., J.E.M.).,Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom (S.A.W., A.E.P.H., A.G., J.E.M.)
| | - Mark Wareing
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom (S.A.W., S.L.G., A.E.P.H., M.W., J.E.M.)
| | - Adam Greenstein
- Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom (S.A.W., A.E.P.H., A.G., J.E.M.).,Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom (H.A.T.P., M.A., A.G.)
| | - Jenny E Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom (S.A.W., S.L.G., A.E.P.H., M.W., J.E.M.).,Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom (S.A.W., A.E.P.H., A.G., J.E.M.)
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12
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Kudo Y, Koh I, Sugimoto J. Localization of Indoleamine 2,3-Dioxygenase-1 and Indoleamine 2,3-Dioxygenase-2 at the Human Maternal-Fetal Interface. Int J Tryptophan Res 2020; 13:1178646920984163. [PMID: 33447047 PMCID: PMC7780199 DOI: 10.1177/1178646920984163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/01/2020] [Indexed: 02/03/2023] Open
Abstract
Immunohistochemical localization of indoleamine 2,3-dioxygenase-1 and indoleamine 2,3-dioxygenase-2, the first and rate-limiting enzyme in tryptophan metabolism along the kynurenine pathway, has been studied in order to better understand the physiological significance of these enzymes at the maternal-fetal interface of human pregnancy with a gestational age of 7 weeks (n = 1) and term placentas (37-40 weeks of gestation, n = 5). Indoleamine 2,3-dioxygenase-1 protein immunoreactivity was found in glandular epithelium of the decidua and the endothelium of the fetal blood vessels in the villous stroma with some additional positive cells in the villous core and in the decidua. The syncytiotrophoblast stained strongly for indoleamine 2,3-dioxygenase-2. Immunoreactivity of kynurenine, the immediate downstream product of indoleamine 2,3-dioxygenase-mediated tryptophan metabolism, showed the same localization as that of indoleamine 2,3-dioxygenase-1 and indoleamine 2,3-dioxygenase-2, suggesting these are functional enzymes. Interferon-γ added to placental villous explant culture markedly stimulated expression level of both mRNA and immunoreactivity of indoleamine 2,3-dioxygenase-1. The different cellular expression and interferon-γ sensitivity of these enzymes at the maternal-fetal interface suggests distinct physiological roles for each enzyme in normal human viviparity.
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Affiliation(s)
- Yoshiki Kudo
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Iemasa Koh
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Jun Sugimoto
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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13
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Muneer A. Kynurenine Pathway of Tryptophan Metabolism in Neuropsychiatric Disorders: Pathophysiologic and Therapeutic Considerations. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2020; 18:507-526. [PMID: 33124585 PMCID: PMC7609208 DOI: 10.9758/cpn.2020.18.4.507] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/04/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
Under physiological conditions 95% of the ingested essential amino acid tryptophan is metabolized by the kynurenine pathway (KP) to yield the ubiquitous co-enzyme nicotinamide adenine dinucleotide, fulfilling cellular energy require-ments. Importantly, the intermediaries of KP exert crucial effects throughout the body, including the central nervous system. Besides, KP metabolites are implicated in diverse disease processes such as inflammation/immune disorders, endocrine/metabolic conditions, cancers and neuropsychiatric diseases. A burgeoning body of research indicates that the KP plays a pathogenic role in major psychiatric diseases like mood disorders and schizophrenia. Triggered by inflammatory processes, the balance between neurotoxic and neuroprotective branches of the KP is disturbed. In preclinical models these discrepancies result in behaviors reminiscent of depression and psychosis. In clinical samples, recent studies are discovering key kynurenine pathway abnormalities which incriminate it in the pathogenesis of the main psychiatric disorders. Harnessing this knowledge has the potential to find disease biomarkers helpful in identifying and prognosticating neuropsychiatric disorders. Concurrently, earnest research efforts directed towards manipulating the KP hold the promise of discovering novel pharmacological agents that have therapeutic value. In this manuscript, an in-depth appraisal of the extant literature is done to understand the working of KP as this applies to neuropsychiatric disorders. It is concluded that this pathway plays an overarching role in the development of major psychiatric disorders, the KP metabolites have the potential to serve as disease markers and new medications based on KP modulation can bring lasting cures for patients suffering from these intractable conditions.
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Affiliation(s)
- Ather Muneer
- Islamic International Medical College, Riphah International University, Rawalpindi, Pakistan
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14
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Broekhuizen M, Klein T, Hitzerd E, de Rijke YB, Schoenmakers S, Sedlmayr P, Danser AHJ, Merkus D, Reiss IKM. l-Tryptophan-Induced Vasodilation Is Enhanced in Preeclampsia: Studies on Its Uptake and Metabolism in the Human Placenta. Hypertension 2020; 76:184-194. [PMID: 32475317 DOI: 10.1161/hypertensionaha.120.14970] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
l-tryptophan induces IDO (indoleamine 2,3-dioxygenase) 1-dependent vasodilation. IDO1 is expressed in placental endothelial cells and downregulated in preeclampsia. Hypothesizing that this may contribute to diminished placental perfusion, we studied l-tryptophan-induced vasodilation in healthy and early-onset preeclampsia placental arteries, focusing on placental kynurenine pathway alterations. Despite IDO1 downregulation, kynurenine pathway metabolite concentrations (measured with ultra-performance liquid chromatography-tandem mass spectrometry) were unaltered in preeclamptic versus healthy placentas. Most likely, this is due to enhanced l-tryptophan uptake, evidenced by increased l-tryptophan levels in preeclamptic placentas. Ex vivo perfused cotyledons from healthy and preeclamptic placentas released similar amounts of l-tryptophan and kynurenine pathway metabolites into the circulations. This release was not altered by adding l-tryptophan in the maternal circulation, suggesting that l-tryptophan metabolites act intracellularly. Maternally applied l-tryptophan did appear in the fetal circulation, confirming placental passage of this essential amino acid. After in vitro incubation of placental arteries with IDO1-upregulating cytokines interferon-γ and tumor necrosis factor-α, l-tryptophan induced vasodilation. This vasodilation was attenuated by both IDO1 and nitric oxide (NO) synthase inhibitors. Despite IDO1 downregulation, l-tryptophan-induced relaxation was enhanced in preeclamptic versus healthy placental arteries. However, cytokine stimulation additionally upregulated the LAT (l-type amino acid transporter) 1 in preeclamptic placental arteries only. Vasodilation to the lipophilic, transporter independent ethyl ester of l-tryptophan was reduced in preeclamptic versus healthy placental arteries, in agreement with reduced IDO1 expression. In conclusion, l-tryptophan induces IDO1- and NO-dependent relaxation in placental arteries, which is determined by l-tryptophan uptake rather than IDO1 expression. Increased l-tryptophan uptake might compensate for reduced IDO1 expression in preeclamptic placentas.
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Affiliation(s)
- Michelle Broekhuizen
- From the Division of Neonatology, Department of Pediatrics (M.B., E.H., P.S., I.K.M.R.).,Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.B., E.H., A.H.J.D.).,Division of Experimental Cardiology, Department of Cardiology (M.B., D.M.)
| | - Theo Klein
- Department of Clinical Chemistry (T.K., Y.B.d.R.)
| | - Emilie Hitzerd
- From the Division of Neonatology, Department of Pediatrics (M.B., E.H., P.S., I.K.M.R.).,Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.B., E.H., A.H.J.D.)
| | | | | | - Peter Sedlmayr
- From the Division of Neonatology, Department of Pediatrics (M.B., E.H., P.S., I.K.M.R.)
| | - A H Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.B., E.H., A.H.J.D.)
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology (M.B., D.M.).,Erasmus University Medical Center, Rotterdam, the Netherlands, Walter Brendel Center of Experimental Medicine (WBex), LMU Munich, Munich, Germany (D.M.)
| | - Irwin K M Reiss
- From the Division of Neonatology, Department of Pediatrics (M.B., E.H., P.S., I.K.M.R.)
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15
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Sander KN, Kim DH, Ortori CA, Warren AY, Anyanwagu UC, Hay DP, Broughton Pipkin F, Khan RN, Barrett DA. Untargeted analysis of plasma samples from pre-eclamptic women reveals polar and apolar changes in the metabolome. Metabolomics 2019; 15:157. [PMID: 31773355 PMCID: PMC6879453 DOI: 10.1007/s11306-019-1600-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/27/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Pre-eclampsia is a hypertensive gestational disorder that affects approximately 5% of all pregnancies. OBJECTIVES As the pathophysiological processes of pre-eclampsia are still uncertain, the present case-control study explored underlying metabolic processes characterising this disease. METHODS Maternal peripheral plasma samples were collected from pre-eclamptic (n = 32) and healthy pregnant women (n = 35) in the third trimester. After extraction, high-resolution mass spectrometry-based untargeted metabolomics was used to profile polar and apolar metabolites and the resulting data were analysed via uni- and multivariate statistical approaches. RESULTS The study demonstrated that the metabolome undergoes substantial changes in pre-eclamptic women. Amongst the most discriminative metabolites were hydroxyhexacosanoic acid, diacylglycerols, glycerophosphoinositols, nicotinamide adenine dinucleotide metabolites, bile acids and products of amino acid metabolism. CONCLUSIONS The putatively identified compounds provide sources for novel hypotheses to help understanding of the underlying biochemical pathology of pre-eclampsia.
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Affiliation(s)
- Katrin N Sander
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
- Centre for Analytical Bioscience, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Dong-Hyun Kim
- Centre for Analytical Bioscience, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Catharine A Ortori
- Centre for Analytical Bioscience, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Averil Y Warren
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Uchenna C Anyanwagu
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Daniel P Hay
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Fiona Broughton Pipkin
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK
| | - Raheela N Khan
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK.
| | - David A Barrett
- Centre for Analytical Bioscience, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
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